Case report: Treatment-resistant depression, multiple trauma exposure and suicidality in an adolescent female with previously undiagnosed Autism Spectrum Disorder

Abstract

High rates of co-occurring depression are commonly reported in youth with Autism Spectrum Disorder (ASD), especially in individuals without intellectual disability (ID). Depression in ASD undermines adaptive behavior and is associated with a higher risk of suicidality. Females with ASD may be particularly vulnerable due to their greater use of camouflaging strategies. Indeed, in comparison to males, ASD is underdiagnosed in females, despite higher rates of internalizing symptoms and suicidality. Trauma exposure may also play a role in the development of depressive symptoms in this population. Moreover, evidence for effective treatments of depression in autistic youth are lacking, with ASD individuals frequently experiencing low efficacy and side effects. We present the case of an adolescent female with previously undiagnosed ASD without ID, admitted for active suicidal plans and a treatment-resistant depression (TRD), occurred after a COVID-19 lockdown in the context of cumulative exposure to stressful life events. Comprehensive clinical assessments performed at intake confirmed severe depression with suicidality. Intensive psychotherapy and different changes in medications were carried out (SSRI, SNRI, SNRI + NaSSA, SNRI + aripiprazole), all of which were ineffective, with persistent suicidal thoughts, often requiring intensive individual monitoring. The patient was finally successfully treated with lithium augmentation of fluoxetine, with no side effects. During hospitalization she was also evaluated by an ASD specialized center, where a diagnosis of ASD was made according to the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R) scores, as well as to clinical judgment of a senior psychiatrist. The present case report shows that clinicians should not overlook undiagnosed autism as a possible cause of TRD, especially in females without ID, where higher rates of under diagnosis may be in part related to their greater use of camouflage. It also suggests that ASD underdiagnosis and resulting unmet needs may be involved in vulnerability to stressful experiences, depression, and suicidality. Furthermore, it shows the complexity of providing care to TRD in youth with autism, suggesting that an augmentation therapy with lithium, a commonly recommended therapeutic strategy for refractory depression in typically developing samples, may also be effective in this population.

Female Teens and Young Adults with Mental Illness Who Are Autistic: How Common Is It and Why Is It Important?

“…If the ASD diagnosis is made, 75% are first diagnosed with another condition and the ASD diagnosis may be delayed 8 years [4]. This makes these conditions more difficult to manage in psychosis [5], anorexia nervosa [6][7][8][9], and anxiety and depression [10,11], with increased risk of suicide [12]. It is well documented that therapy in ASD has to be tailored to the neurodiverse mind or it will not succeed (section 3.3).…”

“…This prevalence strongly suggests seeking ASD is essential in female attempted suicide, with tailored prevention strategies [74]. If the presence of ASD is recognized in attempted suicide in treatment resistant depression the knowledge is of itself therapeutic [11]. The American Psychiatric Association's clinical review journal suggests ADHD as a risk factor for suicide but does not list ASD [75].…”

The Influence of Sleep Disorders on Neurobiological Structures and Cognitive Processes in Pediatric Population with ASD and Epilepsy: A Systematic Review

“…Among the comorbid disorders in the pediatric population with ASD, sleep disorders (SD) stand out, primarily manifesting as difficulties in sleep onset, maintenance, nighttime awakenings, and sleep apnea [9]. Generally, individuals with ASD have a multifactorial etiology, tend to be chronic, and have negative consequences on the patient and/or the family environment, both in their progression and quality of life [10]. Sleep disorders (SD) are reported in 6-25% of the pediatric population, but this figure rises to between 50-95% in children with ASD and epilepsy [11].…”